Method and apparatus for meniscal repair

ABSTRACT

An apparatus for suturing tissue includes first and second needles. A first structure associated with the first needle is adapted and configured to pass a leading portion of the suture from a near side of a tissue to a far side of the tissue. A second structure cooperates with the second needle to capture and secure the suture. Proximal movement of the apparatus after the suture is captured moves the suture from the far side of the tissue to the near side of the tissue.

REFERENCE TO PENDING PRIOR PATENT APPLICATIONS

This patent application claims benefit of:

(i) pending prior U.S. Provisional Patent Application Ser. No.60/802,378, filed May 22, 2006 by Peter Marshall et al. for METHOD ANDAPPARATUS FOR MENISCAL REPAIR (Attorney's Docket No. SCAN-24 PROV); and

(ii) pending prior U.S. Provisional Patent Application Ser. No.60/921,403, filed Apr.2, 2007 by Peter Marshall et al. for METHOD ANDAPPARATUS FOR MENISCAL REPAIR (Attorney's Docket No. SCAN-25 PROV).

The two above-identified patent applications are hereby incorporatedherein by reference.

FIELD OF THE INVENTION

This invention relates to surgical methods and apparatus in general, andmore particularly to surgical methods and apparatus for the repair ofthe meniscus.

BACKGROUND OF THE INVENTION

Looking first at FIGS. 1 and 2, the meniscus 5 is a piece of cartilagelocated in the knee joint, between the top of the tibia 10 and thebottom of the femur 15. Meniscus 5 serves to facilitate stable movementof the tibia and femur relative to one another, and to absorb shock andto spread load.

Meniscus 5 is frequently damaged (e.g., torn) as the result of injuryand/or accident. See, for example, the tear 20 shown in FIG. 3. Adamaged meniscus can impede proper motion of the knee joint and causepain, among other things.

At one time, the standard treatment for a badly damaged meniscus was thepartial or complete removal of the meniscus. However, it wassubsequently recognized that patients having a partial or completeremoval of their meniscus frequently suffered from long term jointproblems, e.g., arthritis.

The current trend is toward repairing a damaged meniscus, rather thanremoving part or all of the meniscus. This approach typically requiresthat tears in the meniscus be closed. There are currently two approachesto closing a tear in the meniscus: suturing and fastening.

Suturing a tear in the meniscus has heretofore been technicallydifficult. This is because the knee joint is a relatively tight spaceand has limited access points, thus making it hard to maneuver suturinginstruments and visualization devices. In addition, there are delicateblood vessels and nerves adjacent to the knee joint (e.g., at the backof the knee) which can be easily damaged, particularly by the sharpneedles used to place the suture.

Due to the technical difficulties of suturing, fasteners have beendeveloped to close a meniscal tear. Many different types of meniscalfasteners have been produced, e.g., arrows, tacks, T-bars,barbs-and-sutures, screws, etc. However, all of the fasteners developedto date tend to suffer from one or more disadvantages. Among these isthe common—and quite significant—disadvantage associated withpositioning a rigid component within the interior of the knee. Moreparticularly, all of the fasteners developed to date incorporate atleast one rigid component into their design. If the rigid component isnot properly positioned at the time of deployment, and/or if the rigidcomponent should subsequently migrate out of position, serious jointabrasion can result.

As a result, there is a significant need for a new and improved methodand apparatus for meniscal repair.

SUMMARY OF THE INVENTION

The present invention provides an improved method and apparatus formeniscal repair which addresses the problems associated with the priorart. More particularly, the present invention comprises the provisionand use of a novel meniscal suturing system which makes suturing of themeniscus easy, safe and reliable.

In one form of the present invention, there is provided apparatus forsuturing tissue, wherein the apparatus comprises:

a housing;

a first needle mounted to the housing;

a second needle mounted to the housing;

a suture having a leading portion and a trailing portion;

a first structure associated with the first needle for passing theleading portion of the suture from a near side of the tissue to a farside of the tissue; and

a second structure associated with the second needle for retracting theleading portion of the suture from the far side of the tissue back tothe near side of the tissue.

In another form of the present invention, there is provided apparatusfor suturing tissue, wherein the apparatus comprises:

a housing;

a first needle mounted to the housing;

a second needle mounted to the housing;

a suture having a leading portion and a trailing portion;

a first structure associated with the first needle for passing theleading portion of the suture from a near side of the tissue to a farside of the tissue;

a second structure associated with the second needle for retracting theleading portion of the suture from the far side of the tissue back tothe near side of the tissue;

a pre-formed, uncinched knot formed in the trailing portion of thesuture; and

a support for releasably supporting the pre-formed, uncinched knotrelative to the housing.

In another form of the present invention, there is provided a method forsuturing tissue, the method comprising the steps of:

providing a suture having a leading portion and a trailing portion,wherein a pre-formed, uncinched knot is formed in the trailing portionof the suture;

passing the leading portion of suture from a near side of the tissue toa far side of the tissue;

retracting the leading portion of the suture from the far side of thetissue back to the near side of the tissue;

passing the retracted leading portion of the suture through thepre-formed, uncinched knot formed in the trailing portion of the suture;and

cinching the knot so as to secure the suture in the tissue.

BRIEF DESCRIPTION OF THE DRAWINGS

These and other objects, features and advantages of the presentinvention will be more fully disclosed in, or rendered obvious by, thefollowing detailed description of the preferred embodiments of theinvention, which is to be considered together with the accompanyingdrawings wherein like numbers refer to like parts and further wherein:

FIG. 1 is a schematic front view of a knee joint;

FIG. 2 is a schematic top view, in cross-section, of the meniscus of theknee joint;

FIG. 3 is a schematic perspective view, in partial section, of themeniscus of the knee joint;

FIGS. 4-16 are a series of views showing a first method and apparatusfor repairing a meniscal tear;

FIGS. 17-30 are a series of views showing a second method and apparatusfor repairing a meniscal tear;

FIGS. 31-65 are a series of views showing a third method and apparatusfor repairing a meniscal tear, with the meniscus being omitted fromselected views in order to simplify the drawing and enhancecomprehension;

FIGS. 66-91 are a series of views showing a fourth method and apparatusfor repairing a meniscal tear, with the meniscus being omitted fromselected views in order to simplify the drawing and enhancecomprehension; and

FIGS. 92-103 are a series of views showing a fifth method and apparatusfor repairing a meniscal tear.

DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

First Preferred Method And Apparatus

Looking first at FIGS. 4 and 5, there is shown an apparatus 100 for usein closing tear 20 in meniscus 5.

More particularly, in one preferred form of the present invention, andstill looking now at FIGS. 4 and 5, a first needle 105 is first advancedso that its distal tip 110 is positioned within, but not completelythrough, meniscus 5.

Next, as seen in FIG. 6, a second needle 115 is advanced completelythrough the meniscus, so that the distal tip 120 of second needle 115 ispositioned on the far side of the meniscus.

Then, and looking now at FIGS. 7-9, a snare 125 is advanced out thedistal end 120 of second needle 115. Snare 125 is formed and arranged sothat when the snare is in its fully-extended position (FIG. 9), the loop130 of snare 125 is axially aligned with the longitudinal axis 135 offirst needle 105. To this end, snare 125 may comprise an elongated body140 having the loop 130 set at its distal end, with loop 130 being setat an angle to the longitudinal axis of elongated body 140. At least oneof loop 130 and elongated body 140 comprises a resilient material, inorder that loop 130 and elongated body 140 may be (i) received withinsecond needle 115, and (ii) loop 130 may project across the longitudinalaxis 135 of first needle 105 when snare 125 is in its fully-extendedposition (FIG. 9).

Next, and looking now at FIG. 10, first needle 105 is advancedcompletely through meniscus 5, so that the distal end 110 of firstneedle 105 extends through loop 130 of snare 125.

Then first needle 105 is used to advance a suture 145 through loop 130of snare 125. This may be effected in a variety of ways.

By way of example but not limitation, and looking now at FIGS. 10-12,suture 145 may be pre-disposed within first needle 105 so that suture145 is carried through the meniscus and through loop 130 of snare 125with the advancement of first needle 105. Then a driver 150 may be usedto eject the leading portion 145L (FIG. 11) of suture 145 from theinterior of first needle 105. To this end, a slot 155 may be provided infirst needle 105 to assist in ejecting leading portion 145L of suture145 from first needle 105. Finally first needle 105 is withdrawn,leaving leading portion 145L of suture 145 extending through (i)meniscus 5, and (ii) loop 130 of snare 125. The approach shown in FIGS.10-12 can be advantageous in many circumstances, since it works wellwith both braided suture and monofilament suture. In this respect itwill be appreciated that braided suture is generally preferable formeniscal repairs, since it tends to form a smaller knot which is lesssusceptible to slipping.

In an alternative approach, where suture 145 has sufficient columnstrength (e.g., where suture 145 comprises relatively thick monofilamentsuture), after first needle 105 is advanced through meniscus 5 (FIG. 10)and through loop 130 of snare 125, the suture can be pushed throughfirst needle 105 so that leading portion 145L of suture 145 extendsthrough both meniscus 5 and loop 130 of snare 125. Then, while suture145 is maintained in place, first needle 105 can be withdrawn, with thecolumn strength of the suture ensuring that leading portion 145L ofsuture 145 does not retreat from its position extending through meniscus5 and loop 130 of snare 125. Of course, this latter approach does sufferfrom the disadvantage that it requires the use of suture with sufficientcolumn strength (e.g., monofilament suture) and hence this approach canbe difficult to practice with conventional braided suture.

Regardless of the particular approach used to achieve the position shownin FIG. 12, once this position has been achieved, the next step is tocarry leading portion 145L of suture 145 back to the near side of themeniscus. More particularly, and looking now at FIGS. 13-15, snare 125is retracted back into second needle 115, and then second needle 115 iswithdrawn back through the meniscus, carrying leading portion 145L ofsuture 145 with it.

Thus, at this point in the procedure, suture 145 will have been passedfrom the near side of the meniscus, across the meniscus and then backagain. Significantly, by appropriately positioning the first needle 105and second needle 115 during the suture passing operation, the suturewill extend across the tear 20 formed in meniscus 5.

Next, the suture is tied down so as to close the tear in the meniscus.This may be done in a variety of ways which will be apparent to thoseskilled in the art in view of the present disclosure. However, in onepreferred form of the invention, a trailing portion 145T of suture 145may be arranged in the form of a pre-formed, uncinched knot 160 disposedabout the exterior of second needle 115 (see, for example, FIGS. 13 and14), with an intermediate portion 145I of suture 145 being disposedwithin apparatus 100. As a result of this construction, when snare 125and second needle 115 carry leading portion 145L of suture 145 backthrough the meniscus, they will also carry leading portion 145L ofsuture 145 back through pre-formed, uncinched knot 160 (FIG. 15), whichis itself formed from trailing portion 145T of that same suture 145. Itwill be appreciated that, as second needle 115 is withdrawn, pre-formed,uncinched knot 160 will slip off the end of second needle 115, intodirect contact with leading portion 145L of suture 145, as the suturepasses back through itself.

Then, and looking now at FIG. 16, suture 145 is pulled taut so as tosimultaneously (i) pull tear 20 closed, and (ii) tighten pre-formed knot160 onto the suture, whereby to fix the suture in position and therebyclose tear 20 in meniscus 5. The trailing end 145T of suture 145 canthen be trimmed away in ways well known in the art, thereby leaving alow-profile suture fixation within the meniscus.

Second Preferred Method And Apparatus

Looking now at FIGS. 17 and 18, there is shown an apparatus 200 for usein closing tear 20 in meniscus 5.

More particularly, in one preferred form of the invention, and stilllooking now at FIGS. 17 and 18, a first needle 205 is first advanced sothat its distal tip 210 is positioned within, but not completelythrough, meniscus 5.

Next, as seen as FIG. 19, a second needle 215 is advanced completelythrough the meniscus, so that the distal tip 220 of second needle 215lies on the far side of the meniscus.

Then, and looking now at FIG. 20, first needle 205 is advanced all theway across meniscus 5.

Then, and looking now at FIGS. 21 and 22, a snare 225 is advanced outthe distal end 220 of second needle 215. Snare 225 is formed andarranged so that when the snare is in its fully-extended position (FIG.22), the loop 230 of snare 225 is axially aligned with the longitudinalaxis 235 of second needle 215. To this end, snare 225 may comprise anelongated body 240 having loop 230 set at its distal end, with loop 230being aligned with the longitudinal axis of elongated body 240.

Next, and looking now at FIG. 23, a suture holder 250 carrying a suture245 is advanced out the distal end 210 of first needle 205. Sutureholder 250 is configured so that the suture holder will carry theleading portion 245 k of suture 245 through loop 230 of snare 225 whenthe suture holder is extended out of first needle 205.

Then suture holder 250 is withdrawn, leaving the leading portion 245L ofsuture 245 extending though loop 230 of snare 225 (FIG. 24).

Next, leading portion 245L of suture 245 is carried back to the nearside of the meniscus. More particularly, and looking now at FIGS. 25-29,snare 225 is retracted back into second needle 215, second needle 215 iswithdrawn back through the meniscus, and then first needle 205 iswithdrawn back through the meniscus.

Thus, at this point in the procedure, suture 245 will have been passedfrom the near side of the meniscus, through the meniscus and then backagain. Significantly, by appropriately positioning first needle 205 andsecond needle 215 during the suture passing operation, suture 245 willextend across tear 20 formed in meniscus 5.

Next, the suture is tied down so as to close the tear in the meniscus.This may be done in a variety of ways which will be apparent to thoseskilled in the art in view of the present disclosure. However, in onepreferred form of the invention, the trailing portion 245T of suture 245may be arranged in the form of a pre-formed, uncinched knot 260 disposedabout the exterior of second needle 215 (see, for example, FIG. 28) sothat when snare 225 and second needle 215 carry leading portion 245L ofsuture 245 back through the meniscus, they will also carry leadingportion 245L of suture 245 back through pre-formed, uncinched knot 260(FIG. 29), which is formed by trailing portion 245T of suture 245. Itwill be appreciated that, as second needle 215 is withdrawn, pre-formed,uncinched knot 260 will slip off the end of second needle 215, intodirect contact with leading portion 245L of suture 245, as the suturepasses back through itself.

Then, and looking now at FIG. 30, trailing portion 245T of suture 245 ispulled taut so as to simultaneously (i) pull tear 20 closed, and (ii)tighten pre-formed knot 260 onto the suture, whereby to fix the suturein position and thereby close tear 20 in meniscus 5. The trailing end245T of suture 245 can then be trimmed away in ways well known in theart, thereby leaving a low-profile suture fixation within the meniscus.

Third Preferred Method And Apparatus

Looking now at FIGS. 31-35, there is shown an apparatus 300 for use inclosing tear 20 in meniscus 5. Apparatus 300 generally comprises asuture passer 301 (FIGS. 31-33), a suture cartridge 302 (FIG. 34) and aknot pusher/cutter 303 (FIG. 35). Specific details of the constructionand function of suture passer 301, suture cartridge 302 and knotpusher/cutter 303 will be disclosed in the course of the followingdiscussion of using apparatus 300 to close tear 20 in meniscus 5.

Looking now at FIGS. 31-33, 36 and 37, suture passer 301, with suturecartridge 302 mounted thereon, is first manipulated so that its firstneedle 305 and its second needle 315 are advanced so that their distaltips 310, 320 are passed completely through meniscus 5.

Next, as seen as FIGS. 38-39, a suture holder 350 carrying a suture 345is advanced out distal end 310 of first needle 305. Suture holder 350 isconfigured so that the suture holder will carry the leading portion 345Lof suture 345 through a slot 330 of second needle 315 when the sutureholder is extended out of first needle 305.

Then, as shown in FIGS. 40 and 41, an ejector wire 351 is used to ejectleading portion 345L of suture 345 from suture holder 350.

At this point, suture holder 350 is withdrawn, leaving leading portion345L of suture 345 extending though slot 330 of second needle 315. SeeFIGS. 42 and 43. Then an obturator 352 is advanced within second needle315 so as to pin leading portion 345L of suture 345 to second needle315.

Next, suture passer 301 is retracted so that its first needle 305 andsecond needle 315 are withdrawn from the meniscus. See FIGS. 44 and 45.Thus, at this point in the procedure, suture 345 will have been passedfrom the near side of the meniscus, through the meniscus and then backagain. Significantly, by appropriately positioning first needle 305 andsecond needle 315 during the suture passing operation, suture 345 willextend across tear 20 formed in meniscus 5.

Next, the suture is tied down so as to close the tear in the meniscus.This may be done in a variety of ways which will be apparent to thoseskilled in the art in view of the present disclosure. In one preferredform of the invention, this is accomplished in the following way. First,as shown in FIG. 46, suture cartridge 302 is dismounted from suturepasser 301. Then suture cartridge 302 is mounted to knot pusher/cutter303 (FIG. 47) and locked in place (FIG. 48). At this point, and lookingnow at FIGS. 49 and 50, suture cartridge 302 is ready to receive leadingportion 345L of suture 345. Next, leading portion 345L of suture 345 isinserted into a loop 353 of a snare basket 354, as shown in FIGS. 51-53.Snare basket 354 essentially comprises a conventional suture threadercomponent, or needle threader component, in the sense that a collapsibleloop is formed at the end of a pullable tab. Then snare basket 354 isretracted, carrying leading portion 345L of suture 345 through apre-formed, uncinched knot 360 formed in the trailing portion 345T ofsuture 345 and disposed at the tip of knot pusher/cutter 303. See FIGS.54-56. It will be appreciated that as snare basket 354 carries leadingportion 345L of suture 345 through pre-formed, uncinched knot 360, thesuture passes back through itself.

Then, and looking now at FIGS. 57-59, knot pusher/cutter 303 is advanceddistally so as to bring pre-formed, un-cinched knot 360 to the near sidesurface of the meniscus. Next, as shown in FIGS. 60 and 61, pre-formed,un-cinched knot 360 is tightened. Then leading portion 345L of suture345 is trimmed away by knot pusher/cutter 303 (FIGS. 62 and 63).Finally, knot pusher/cutter 303 is removed, leaving suture 345 closingthe tear in the meniscus (FIGS. 64 and 65) with a low-profile suturefixation.

In one preferred form of the invention, and looking now at FIG. 60, knotpusher/cutter 303 comprises a shaft S having a central bore B, acounterbore CB and a side opening SO. A hollow ram R, having a ram sideopening RSO, is slidably disposed within bore B of shaft S. Prior toknot deployment, the pre-formed, uncinched knot 360 is seated withincounterbore CB; and after leading portion 345L of suture 345 is passedthrough pre-formed, uncinched knot 360, leading portion 345L is drawnthrough ram side opening RSO and shaft side opening SO; and when theknot is to be separated from shaft S, ram R is moved distally, firstpushing the knot out of the shaft and, after cinching, thereaftercutting leading portion 345L of suture 345 by virtue of moving sideopening SO out of alignment with ram side opening RSO.

In one preferred form of the invention, the cinched knot is separatedfrom shaft S in a first discrete step, and then the suture is cut in asecond discrete step.

Fourth Preferred Method And Apparatus

Looking now at FIG. 66, there is shown an apparatus 400 for use inclosing tear 20 in meniscus 5. Apparatus 400 generally comprises ahandle 401, a needle cartridge 402 and a pusher/cutter 403.Pusher/cutter 403 is similar to suture cartridge 302 discussed above, inthe sense that it carries a pre-formed, uncinched knot, etc., as willhereinafter be discussed. Specific details of the construction andfunction of handle 401, needle cartridge 402 and pusher/cutter 403 willbe disclosed in the course of the following discussion of usingapparatus 400 to close tear 20 in meniscus 5.

Looking now at FIGS. 67 and 68, apparatus 400 is manipulated so that itsfirst needle 405 and its second needle 415 are advanced so that theirdistal tips 410, 420 are passed completely through meniscus 5.

Next, as seen as FIGS. 69 and 70, a suture holder 450 carrying a suture445 is advanced out distal end 410 of first needle 405. Suture holder450 is configured so that the suture holder will carry the leadingportion 445L of suture 445 through a slot 430 of second needle 415 whenthe suture holder is extended out of first needle 405.

Then, as shown in FIGS. 71 and 72, an ejector wire 451 is used to ejectleading portion 445L of suture 445 from suture holder 450.

At this point, suture holder 450 is withdrawn, leaving leading portion445L of suture 445 extending though slot 430 of second needle 415. SeeFIGS. 73 and 74. Then an obturator 452 is advanced within second needle415 so as to pin leading portion 445L of suture 445 to second needle415.

Next, handle 401 is retracted so that its first needle 405 and secondneedle 415 are withdrawn from the meniscus. See FIG. 75. Thus, at thispoint in the procedure, suture 445 will have been passed from the nearside of the meniscus, through the meniscus and then back again.Significantly, by appropriately positioning first needle 405 and secondneedle 415 during the suture passing operation, suture 445 will extendacross tear 20 formed in meniscus 5.

Next, the suture is tied down so as to close the tear in the meniscus.This may be done in a variety of ways which will be apparent to thoseskilled in the art in view of the present disclosure. In one preferredform of the invention, this is accomplished in the following way.Looking now at FIGS. 76 and 77, pusher/cutter 403 is ready to receiveleading portion 445L of suture 445. Then, as shown in FIGS. 78-81,leading portion 445L of suture 445 is inserted into a loop 453 ofpusher/cutter 403. Again, loop 453 of pusher/cutter 403 essentiallycomprises a conventional suture threader component, or needle threadercomponent, in the sense that a collapsible loop is formed at the end ofa pullable shaft. Then pusher/cutter 403 is detached from handle 401,carrying leading portion 445L of suture 445. Next, leading portion 445Lof suture 445 is passed through a pre-formed, uncinched knot 460disposed at the tip of pusher/cutter 403 (FIGS. 82-84). It will beappreciated that as leading portion 445L of suture 445 is passed throughpre-formed, uncinched knot 460, the suture passes back through itself.

Then, and looking now at FIGS. 85 and 86, pusher/cutter 403 is advanceddistally so as to bring pre-formed, un-cinched knot 460 to the near sidesurface of the meniscus. Next, as shown in FIGS. 87-89, the pre-formedknot is tightened. Then leading portion 445L of suture 445 is trimmedaway by pusher/cutter 403 (FIGS. 90 and 91). Finally, pusher/cutter 403is removed, leaving suture 445 closing the tear in the meniscus with alow-profile suture fixation.

In one preferred form of the invention, and looking now at FIG. 88,pusher/cutter 403 comprises a shaft S having a central bore B, acounterbore CB and a side opening SO. A hollow ram R, having a ram sideopening RSO, is slidably disposed within bore B of shaft S. Prior toknot deployment, the pre-formed, uncinched knot 460 is seated withincounterbore CB; and after leading portion 445L of suture 445 is passedthrough pre-formed, uncinched knot 460, leading portion 445L is drawnthrough ram side opening RSO and shaft side opening SO; and when theknot is to be separated from shaft S, ram R is moved distally, firstpushing the knot out of the shaft and, after cinching, thereaftercutting leading portion 445L of suture 445 by virtue of moving sideopening SO out of alignment with ram side opening RSO.

In one preferred form of the invention, the cinched knot is separatedfrom shaft S in a first discrete step, and then the suture is cut in asecond discrete step.

Fifth Preferred Method And Apparatus

In yet another preferred form of the present invention, the pre-formed,uncinched knot can be stored in a disposable tip that is releasablymounted to the needles, with the needles themselves being releasablymounted to the handle, and with the disposable tip being connectable toa pusher after the suture has been passed through the tissue. Thisconstruction has the advantage that (i) a single handle can be used forboth the needles and pusher, and (ii) a single handle and a singlepusher can be provided even where a patient may require multiplestitches (i.e., multiple disposable tips with multiple pre-formed,uncinched knots).

More particularly, and looking now at FIGS. 92-97, there is shown anapparatus 500 for use in closing tear 20 in meniscus 5. Apparatus 500generally comprises a handle 501, a needle cartridge 502, and a pusher503. Needle cartridge 502 includes a disposable tip 504 which containsthe pre-formed, uncinched knot 560. Specific details of the constructionand function of handle 501, needle cartridge 502, pusher 503 anddisposable tip 504 will be disclosed in the course of the followingdiscussion of using apparatus 500 to close tear 20 in meniscus 5.

The apparatus 500 is prepared for use by mounting needle cartridge 502mounted to handle 501, and mounting pusher 503 to handle 501 (FIG. 98).

Apparatus 500 utilizes the same suture passing approach as apparatus 400in order to pass and retract the leading portion of the suture from thenear side of the meniscus to the far side of the meniscus and then back.Once the leading portion 545L of suture 545 is retracted to the nearside of the meniscus, leading portion 545L of suture 545 is threadedinto loop 553 of a snare 554. Snare 554 in turn extends through the bodyof disposable tip 504, including through pre-formed, uncinched knot 560,and exits disposable tip 504 before being attached to needle cartridge502 at 555. Then, pusher 503 is detached from handle 501 (FIG. 99) andis brought down into engagement with disposable tip 504 (FIGS. 100-102).Pusher 503 is then withdrawn, carrying disposable tip 504 with it. Asdisposable tip 504 is withdrawn from needle cartridge 502, snare 554 ispulled back through the retreating disposable tip 504 thereby threadingsuture 545L through pre-formed, uncinched knot 560. Thereafter, suture545 is secured in the manner previously discussed.

Additional Aspects Of The Invention

It will be appreciated that needles 105, 115, 205, 215, 305, 315, 405,415, etc. may be straight (as shown) or curved as desired.

Furthermore, the apparatus 100, 200, 300, 400, 500 may be used witheither a medial or lateral approach.

Modifications

It is to be understood that the present invention is by no means limitedto the particular constructions herein disclosed and/or shown in thedrawings, but also comprises any modifications or equivalents within thescope of the invention.

1-28. (canceled)
 29. A method for suturing tissue, comprising: providinga suturing apparatus including: a housing; a first needle mounted to thehousing; a second needle mounted to the housing, the second needleincluding a slot extending through an outer surface of the second needleand positioned proximal to a distal end of the second needle; a firststructure associated with the first needle; a second structureassociated with the second needle; providing a length of sutureincluding a leading portion, a trailing portion, a pre-formed uncinchedknot formed in the trailing portion of the suture; actuating the firststructure associated with the first needle to pass the leading portionof the suture to the slot of the second needle; and actuating the secondstructure associated with the second needle to retain the leadingportion of the suture within the slot.
 30. The method of claim 29,wherein at least one of the first and second needles is movably mountedto the housing.
 31. The method of claim 29, wherein the first structurecomprises a suture holder extendable out of the first needle, the sutureholder including a suture engager formed at the end of an angled shaft.32. The method of claim 29, wherein the first structure comprises anejector wire.
 33. The method of claim 32, further comprising:translating the ejector wire through the slot associated with the secondneedle to pass the leading portion of the suture through the slot of thesecond needle.
 34. The method of claim of claim 29, wherein the secondstructure comprises an obturator.
 35. The method of claim 34, furthercomprising: translating the obturator through the second needle tocapture the leading portion of the suture within the slot of the secondneedle.
 36. The method of claim 29, further comprising: passing theleading portion of the suture from a near side of a tissue to a far sideof the tissue.
 37. The method of claim 29, further comprising:retracting the leading portion of the suture from a far side of a tissueto a near side of the tissue.
 38. The method of claim 29, furthercomprising: cinching the knot to secure the suture to a tissue.